Cheat sheet for office visits

Alma 3323 · Oct 23, 2012

I hope to be starting in the same situation and wonder if anyone has a brain sheet for clinic visits too.

featherzRN, MSN · Oct 23, 2012

Problem is, it kinda depends on the clinic. I have worked many different clinics, and all have different requirements - we usually post a cheat sheet for that clinic around the clinic area. For example, one clinic I work per diem for has for a diabetic patient before going in with doc - urine dip, waist measurement, fingerstick, full medication reconciliation and a diabetic flow sheet... My other clinic does NONE of those things unless requested after the doctor sees the patient.

Neither of my clinics will have the nurse do a throat swab unless the doc requests one.

kirbyjoe · Mar 3, 2015

Hi, I just moved here from LTC/Geriatric specialty and this forum is soooooo much nicer!! :) (If you ever worked in LTC, you know exactly what I mean!)
This is a completely COMPLETELY new kind of nursing for me, and this might sound a little "duh" but I'm having trouble remembering implications for different kinds of office visits. Anyone have a little cheat sheet idea I might borrow? For instance, things to remember for each well-child visit, for each yearly physical, for certain symptoms they might verbalize (sore throat=swab 'em, dysuria=clean catch, got that much). ... I am a hard worker and when I am well trained/experienced I know I can be a great part of the team, but for now I keep forgetting stuff and I feel so dumb! Any help/advice would be GREATLY appreciated.
P.S. While in training I am working with many different providers, and have given them all their own pages in my little notebook as to their preferences. That helps, but I really need a cheat sheet on typical office visits/implications, too.

Keep copies! I have notebook with alphabet dividers, each year I pull the one from the year before, change the dates and re-submit. It also helps doing new prior auths what worked before works again, just personalize

Ann.E · Apr 8, 2015

I experienced the same thing as I float around to different providers at a primary care clinic. It's true that each provider is different and it can get a little confusing at times. We have found that if we keep a sheet in our screening room right by the computer it's super helpful. For example, we ask every patient if they have had any signs or symptoms of depression, but sometimes it's easy to forget at what age you start asking. Or at what age to start asking if they smoke or use tobacco. These ages are taped up by the computer so it's easy to locate and catches your eye before the patient leaves the screening room. Our well child checks include running a report through ASIIS to see what imms are due, checking to see if they have had a lead level completed, hemoglobin or urine sample. Each of our doctors likes these things to be done at different ages. For our diabetics we are checking to make sure their imms are up to date, they get a glucose check at each visit, shoes and socks are taken off at each visit and they get a yearly foot exam. If someone has back pain and hasn't seen this provider before for that compliant, we will get a urine sample. And we get a urine sample with any type of urinary symptoms. We also don't swab patients unless the provider asks because we found that majority of the time our nurses and MAs were jumping the gun and wasting supplies. If you see OB patients that's a whole different list of things that need to be done. For our providers that see OB patients we have a list of everything you should be checking on and at what weeks (for example when the patient should have a tdap shot, when they should have had their GBS completed, what is include in a first time ob visit). But most of these lists are provider specific. Good luck and don't worry, soon these things will come to naturally